Introduction
What is the difference between letter and stamp date?
Letter date: Processed date
Stamped date: Received date
In which app would the appeal template open?
MS Word
From which application would you call payer?
Jabber
How many times do we follow up with payer in LOST PHI scenario?
2
What is the usual follow up time that is assigned for the assigned task to be completed?
14 days
Which website has a chat option?
Availity
In which tab will you find member ID number?
Patient Info
What is Initial Review notes?
First note on the account
What are the uses the documentation tab?
1. We can find account related documents
2. We can draft appeal
3. Upload any documentation if required
We should use contract language, federal/state law, provider manual language in our appeal to overturn the denial. Where do we get this information?
Appeal templates
In which option or tile will you find date calculator option?
Toolbox
Difference between scheduled and unscheduled patients?
Scheduled Patients
•Scheduled Inpatient – patient’s level of care meets inpatient criteria
•Scheduled Outpatients – patients who are not admitted to inpatient (Ex. Ambulatory Surgery, Catheterizations, radiology, nuclear medicine)
Unscheduled Patients
•Emergency Department – Most common and usually requires notification within 24 hours or next business day
•Direct/Urgent – patient is admitted directly to the hospital by the physician because the patient’s medical condition meets the required level of care
Based on Recovery 201 session, what are the additional documentation that a payer could request from provider besides Medical records, claim form and EOB? Name atleast 3.
Business Associate Agreement
Waiver of liability
Member consent
Dispute form
What would the assigned task be, if the correspondence has to be reviewed in the documentation tab?
Review Correspondence
Name three ways on how you can payer contact info?
1. Previous notes
2. Payer website
3. Check with peers
What does "Assigned Task" indicate?
It indicates the next step that has to be taken on the account
What are the main differences between a UB-04 and a CMS 1500 (HCFA) claim?
1. Change in DOS
2. CPT and Revenue Codes
3. Type of Bill
In which tab do you find appeal templates?
Documentation
When do we use billing tab?
Never
Which claims can we downgrade and when?
Inpatient claims can be downgraded to outpatient claims
This is done, once we have exhausted all levels of appeal and still are within TFL to submit outpatient claim
What is 837 and 835 format?
•837 – Electronic version of the claim being sent to the plan
•835 – Electronic response to the claim from plan (denial, payment, or rejection)
Name 3 ways on how you can identify an inpatient claims?
1. Type of bill
2. Date of service
3. No CPTs or HCPCS on the claim form
Differentiate between Rush and Alert?
Rushes: Accounts with a true submission due date of 2 weeks or less.
Alerts: Must be worked immediately. Client or supervisor priority
When can we move an account to closure ?
(Hint: There are 3 reasons)
1. Claim Paid
2. Exhausted all levels of appeals
3. Balance is patient responsibility
Full form of IRAC?
ISSUE
RULE
ANALYSIS
CONCLUSION